
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">

<html xmlns="http://www.w3.org/1999/xhtml">

<head>

<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />

<title>Contact Form</title>


<!-- Contact Form Start -->

<script src="http://ajax.googleapis.com/ajax/libs/jquery/1.7.2/jquery.min.js"></script>

<script src="cfg-contactform-21/js/contactform.js"></script>
<link href="cfg-contactform-21/css/contactform.css" rel="stylesheet" type="text/css" />

<!-- Contact Form End -->


</head>

<body>

<div class="cfg-contactform" id="cfg-contactform-21">

<div class="cfg-contactform-content">




<div class="cfg-element-container">

	<div class="cfg-element-set" id="cfg-element-21-6-set" >
		<div class="cfg-element-content">
		<span class="cfg-title "  name="cfg-element-21-6" id="cfg-element-21-6">Inscription</span>
		</div>
	</div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-7-label" ><span class="cfg-label-value">Nom</span><span class="cfg-required">*</span></label>

	<div class="cfg-element-set" id="cfg-element-21-7-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-7" id="cfg-element-21-7"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-8-label" ><span class="cfg-label-value">Prénom</span><span class="cfg-required">*</span></label>

	<div class="cfg-element-set" id="cfg-element-21-8-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-8" id="cfg-element-21-8"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-10-label" ><span class="cfg-label-value">Email</span><span class="cfg-required">*</span></label>

	<div class="cfg-element-set" id="cfg-element-21-10-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-10" id="cfg-element-21-10"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-12-label" ><span class="cfg-label-value">Date de Naissance</span></label>

	<div class="cfg-element-set" id="cfg-element-21-12-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-12" id="cfg-element-21-12"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-14-label" ><span class="cfg-label-value">N° Tel</span></label>

	<div class="cfg-element-set" id="cfg-element-21-14-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-14" id="cfg-element-21-14"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-15-label" ><span class="cfg-label-value">Adresse</span></label>

	<div class="cfg-element-set" id="cfg-element-21-15-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-15" id="cfg-element-21-15"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-17-label" ><span class="cfg-label-value">Login</span><span class="cfg-required">*</span></label>

	<div class="cfg-element-set" id="cfg-element-21-17-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-17" id="cfg-element-21-17"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<label class="cfg-label" id="cfg-element-21-18-label" ><span class="cfg-label-value">Mot de Passe</span><span class="cfg-required">*</span></label>

	<div class="cfg-element-set" id="cfg-element-21-18-set" >
		<div class="cfg-element-content">
		<input type="text" class="cfg-type-text cfg-form-value " name="cfg-element-21-18" id="cfg-element-21-18"  />
		</div>
	</div>

	<div class="cfg-clear"></div>
</div>


<div class="cfg-element-container">

	<div class="cfg-element-set" id="cfg-element-21-20-set" >
		<div class="cfg-element-content">
		<input type="submit" class="cfg-submit " name="cfg-element-21-20" id="cfg-element-21-20" value="Valider"   />
		</div>
	</div>
</div>




<div class="cfg-loading">&nbsp;</div>

</div><!-- cfg-contactform-content -->

</div><!-- cfg-contactform -->

</body>


</html>